Concepts Exam 2 Study Guide
Concepts Exam 2 Study Guide Nurs 20263
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This 7 page Study Guide was uploaded by Kendall Frenkel on Wednesday March 30, 2016. The Study Guide belongs to Nurs 20263 at Texas Christian University taught by Young in Fall 2015. Since its upload, it has received 32 views. For similar materials see Health assessment:concepts in Nursing and Health Sciences at Texas Christian University.
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Date Created: 03/30/16
Study Guide Exam II Anatomy of lung Right Lung: Shorter than left lung due to the liver 3 lobes: upper, middle and lower Left Lung Narrower than right lung due to the heart 2 Lobes: upper and lower Anterior Assessment: Contains mostly upper and middle lobes Lungs begin at Clavicle and go to T6 Posterior: Contains mostly lower lobes Lungs begin at C7 and go to T10 or T12 with deep inspiration Lateral: Lungs start at Apex and go to T7 or T8 Pleurae Slippery serous membrane that cover the lungs and chest wall lubricating the lungs to avoid friction Auscultation techniques Posterior Chest: Take deep breaths and auscultate 10 spots on the back using the drop down method Start at C7 and move down to T10 Anterior: Start above clavicle and use drop down method You will hear bronchovesicular sounds in center And vesicular sounds on periphery Inspection of chest – anterior, posterior and lateral Posterior: Spine should be in a straight line Thorax should be symmetric with downward slopping ribs AP Diameter should be less than the transverse diameter…ratio of 1:2…if equal it is barrel chest Anterior: Shape and configuration of chest wall o Costal muscle should be 90 degrees Facial expression should be relaxed with unconscious breathing They should be alert and cooperative Lateral Lateral to AP diameter should be 1:2 Causes of unequal chest expansion Occurs with marked atelectasis, lobar pneumonia, pleural effusion, thoracic trauma such as fractured ribs or pneumothorax. Can occur when part of the lung is guarded or collapsed Signs and symptoms associated with COPD Sitting in tripod position (leaning forward with arms braced against knees chair or bed) Wheezing Ribs are horizontal and chest appears to be in constant inspiration Clubbing Use of accessory muscles Bronchophony is associated with? Rather than breath sounds being muffled, they are clear. To test for this you ask the person to repeat 99 while listening with your stethoscope o Normal: sound is muffled, soft and indisctinct o Abnormal: you can hear a clear 99 Risk factors for heart disease Causes include: Interaction of genetic, environmental and lifestyle factors Risk Increases with age Women tend to get it later than men because of menopause 9 modifiable factors Lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, inadequate diet, alcohol use, and lack of regular physical activity Location of apex and base of the heart Base: at the top of the heart Apex: at the bottom of the heart Know: S1, S2, S3, S4 sounds S1: first heart sound, occurs with the closure of the AV valves and signals the beginning of systole. Usually loudest in the apex. S2: occurs with closure of the semilunar valve and signals the end of systole. Usually loudest at the base. S3: ventricular filing that creates vibration that can be heard over the chest. S3 occurs when the ventricles are resistant to filling during the early rapid filling phase S4: occurs at the end of diastole when the ventricle is resistant to filling. The atria contract and push blood into a noncompliant ventricle creating the vibrations known as S4 which occur just before S1 Splitting of heart sounds Mitral and tricuspid components are heard separately (normal but uncommon) o S2 split is a normal phenomenon that occurs at the end of respiration Inspiration separates the time of the aortic and pulmonic valves closing and so instead of one dub you hear a split sound T-Dub A Thrill is?? A palpable vibration that signifies turbulent blood flow and directs you to locate the origin of loud murmurs What do you know about percussion of the heart? Percussion has been replaced with a chest X-ray or ECG because they are more accurate Percussion is also of limited use with the female breast tissue or in an obese person or a person with a muscular chest wall. Arterial system versus venous system Arterial: Heart pumps freshly oxygenated blood through the arteries to all of the body tissues High pressure system Arteries can stretch and recoil thanks to elastic fibers All arteries have a pressure wave or pulse to push blood through them Venous: Veins are parallel to arteries but push blood in the opposite direction Veins absorb CO2 and waste products from the periphery and carry them to the heart More veins than arteries and they lay closer to skin surface Low pressure system Mechanism they use to keep blood flowing: o Contraction of skeletal muscles o Pressure gradient created by breathing causing thoracic pressure to decrease and abdominal pressure to increase o Intraluminal valves to ensure unidirectional flow Know location of peripheral pulses Temporal Artery: palpated in front of the ear Carotid Artery: palpated in groove between sternomastoid and trachea Brachial artery: runs in the biceps-triceps furrow of the upper arm and surfaces at the antecubical fossa in the elbow medial to the biceps tendon. Bifurcates the radial and ulnar artery Radial Artery: lies medial to the radius at the wrist Ulnar Artery: lies medial to the ulna but is deeper and harder to get to then the radial Femoral Artery: back of the thigh Dorsalis Pedis: on top of the foot with a great and small saphenous vein running down the leg medially How do you assess the carotid arteries? Palpate each carotid medial to the sternomastoid muscle in the neck Avoid excessive pressure Palpate only one at a time to avoid compromising blood flow to the brain Eyelids Two Rapid Window Shades that further protect the eyes from injury, strong light and dust. Upper eyelid Stronger, more mobile Tarsal plates are strips of connective tissue that give it its shape o Tarsal plates contain meibomian glands that are modified sebaceous glands that secrete an oily lubricating material onto the lids Eyelashes Short hairs in double or triple rows that curve outward from lid margins filtering out dust and dirt Palpebral Fissure Elliptical open space between the eye lid Ptosis Drooping of the upper eyelid Canthus: Corner of the eye, angle where the lids meet Inner Canthus o Caruncle is a small, fleshy mass containing sebaceous glands Which cranial nerves are responsible for extraocular movement of eye? CN VI Abducens nerve Innervates lateral rectus muscle CN IV Trochlear nerve Innervates superior oblique muscle CN III Oculomotor nerve Innervates all the rest: superior, inferior, and medial rectus and the inferior oblique muscles What is intraocular pressure? Anterior and posterior chambers of the eye contain clear, watery aqueous humor that is produced continually by the ciliary body It is determined by the balance between the amount of aqueous pressure produced and resistance to its outflow at the angle of the anterior chamber Review visual fields and visual pathways of visual examinations? Visual Fields Objects reflect light. The light rays are reflected through a transparent media and hit the retina. The retina transforms the light into nerve impulses that are conducted through the optic nerve and the optic tract to the visual cortex. Image formed in retina is upside down and reversed from actual appearance in outside world. Visual Pathways of Visual Examination Test Central Visual Acuity o Snellen Eye Chart: most commonly and most accurate used. It has lines and letters arranged in decreasing size o Near vision-jaeger Card Test vision fields o Confrontation test: screens for loss of peripheral vision. Compares the persons peripheral vision with your own, assuming that yours is normal. What is visual accommodation? Adaptation of the eye for near vision Accomplished by increasing the curvature of the lens through muscles in the ciliary body Components of accommodation that can be observed are convergence of the axes of the eyeballs and pupillary constriction What is pupillary light reflex? Normal constriction of the pupils when bright light shines on the retina No conscious control over it The sensory afferent link is Cranial nerve II (optic) and the motor path is cranial Nerve III (oculomotor) What is presbyopia? Decrease in accommodation power with aging A suggested test is holding a card up to a persons face. If they have to push it further away to read it, it’s a big indicator Signs and symptoms of venous stasis? Symptoms Aching pain in lower lower calf of lower leg, worse at end of the day and with prolonged standing, sitting. Signs Lower leg edema that can not be resolved with diuretic therapy Increased venous pressure causing red blood cells to leak out into skin Venous ulcers are shallow and may contain granulation tissue RBC break down hemosiderin (iron deposits) which are brown pigment deposits Who is more likely to experience venous disease? People who undergo prolonged sitting, standing, or bed rest because they do not benefit from the milking action that walking accomplishes. Smokers, diabetes mellitus, hypertension, non Hispanic blacks Lymphatic system This is a completely separate vessel system that retrieves excess fluid and plasma proteins from the interstitial spaces and returns it back into the blood stream. Fluid moves from a pressure system- at the arterial end, hydrostatic pressure from the heart pumping pushes somewhat more fluid out of the capillaries than the veins can absorb. This extra fluid goes into lymph vessels and is eventually returned back into the blood stream. The right lymphatic duct empties into the right subclavian vein and it drains the right side of the head and the neck, right arm, right side of thorax, right lung and pleura, right side of the heart, and the right upper section of the liver. The thoracic duct drains the rest of the body. It empties into the left subclavian vein. The function of the lymphatic system are to o 1) conserve fluid and plasma proteins that leak out of the capillaries o 2) form a major part of the immune system that protects the body against disease o 3) absorb lipids from the small intestine. Lymphatic capillaries start as microscopic open ended tubes which take up interstitial fluid, they them turn into vessels and drain into larger ones. These vessels have valves, so flow of lymph is one way up. Flow is propelled by contraction of the skeletal muscles, by pressure changes secondary to breathing, and by contraction of the vessel walls themselves. Lymph nodes of the peripheral vascular system Small, oval clumps of lymphatic tissue located at intervals along the vessels. Most are arranged in groups, both deep and superficial. They filter fluid before it returns to blood stream and B and T cells scan for pathogens. Cervical nodes: drain the head and neck Axillary nodes: drain the breast and upper arm Epitrochlear node: the ante cubital fossa and drains the hand and lower arm Inguinal nodes: in the groin drain most of the lymph of the lower extremity, the external genetalia, and the anterior abdomen wall Organ of Corti Sensory organ of hearing o Numerous receptor hair cells, as they bend they mediate vibrations into electric impulses Air conduction and bone conduction of hearing Air conduction is greater than Bone conduction Air Conduction: When sound waves go directly into the ear Bone Conduction: Vibrations enter the ear drum through the cranial bones Function of hearing involves the auditory system at three levels 1. Peripheral: ear transmits sound and converts its vibrations into electrical impulses which can be analyzed by the brain. The amplitude is how loud the alarm is and the frequency is the pitch or number of cycles per second. 2. Brainstem: binaural interaction, which permits locating the direction of a sound in space and identifying the sound 3. Cortex: interprets the meaning of sound and begins the appropriate responses. All of this happens in the split second it takes to react to an alarm. What are causes of hearing loss? Conduction? Sensorineural? Anything that obstructs the transmission of sound impairs hearing. Conduction: Involves a mechanical dysfunction of the internal or middle ear o Partial loss because the person is able to hear if the sound amplitude is increased enough to reach normal nerve elements in the ear o Can be caused by impacted cerumen, foreign bodies, a perforated tympanic membrane, pus or serum in the middle ear and ostosclerosis Sensorineural: o Pathology of the inner ear, CN VIII, or the auditory areas of the cerebral cortex. o A simple increase in amplitude may not enable a person to better hear and understand words o Also known as presbycusis: a gradual nerve degeneration that occurs w aging, and by ototoxic drugs that can affect the hair cells Hormones and impact on breast tissue At puberty, estrogen stimulates breasts to enlarge Breasts of nonpregnant women change with the ebb and flow of hormones during the menstrual cycle The beginning of breast development precedes puberty by 2 years Pregnancy stimulates the expansion of the ductal system, fatty tissue and the development of true secondary alveoli After menopause estrogen and progesterone decrease cause breast glandular tissue atrophy Population most at risk of breast cancer? White woman have higher risk starting at 45 years of age African American women have higher risk under 45 years of age Heavy alcohol consumption, prolonged hormone therapy, low physical activity and unhealthy diet all increase the risk. Gynecomastia A benign growth of breast tissue in males during adolescence Only temporary Can be unilateral or bilateral Review breast examination Women should become comfortable with look and feel of their breasts o Exam should be done monthly, 4-7 days into menstrual cycle (breasts are smallest) o Palpate in shower or laying down. Press your 3 middle fingers in circular motion using 3 levels of pressure. Follow an up and down pattern Mental status examination, when, where, why? Inferred through assessment of an individuals behavior Usually can assess through the context of an health history interview It is important to perform a full mental status exam when you discover any abnormality in affect or behavior in the following situations: o Brief screening suggests anxiety or depression o Family members are concerned o Brain lesions o Aphasia o Symptoms of a psychiatric mental illness
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